Bictegravir Use During Pregnancy: A Multi-Center Retrospective Analysis Evaluating HIV Viral Suppression and Perinatal Outcomes.

This study describes the largest cohort to date (n=147) of pregnant patients living with HIV on bictegravir (BIC). BIC in pregnancy was associated with high levels of viral suppression and similar perinatal outcomes to published literature. These findings support consideration for use of BIC in management of HIV during pregnancy.

Society for Maternal-Fetal Medicine Statement: Clinical considerations for the prevention of respiratory syncytial virus disease in infants.

Respiratory syncytial virus is a leading cause of lower respiratory tract illness globally in children aged <5 years. Each year, approximately 58,000 hospitalizations in the United States are attributed to respiratory syncytial virus. Infants aged ≤6 months experience the most severe morbidity and mortality. Until recently, prevention with the monoclonal antibody, palivizumab, was only offered to infants with high-risk conditions, and treatment primarily consisted of supportive care. Currently, 2 products are approved for the prevention of respiratory syncytial virus in infants. These include the Pfizer bivalent recombinant respiratory syncytial virus prefusion F protein subunit vaccine, administered seasonally to the pregnant person between 32 0/7 and 36 6/7 weeks of gestation, and the monoclonal antibody, nirsevimab, administered to infants aged up to 8 months entering their first respiratory syncytial virus season. With few exceptions, administering both the vaccine to the pregnant person and the monoclonal antibody to the infant is not recommended. All infants should be protected against respiratory syncytial virus using one of these strategies. Key considerations for pregnant individuals include examining available safety and efficacy data, weighing accessibility and availability, and patient preferences for maternal vaccination vs infant monoclonal antibody treatment. It will be critical for maternal-fetal medicine physicians to provide effective and balanced counseling to aid patients in deciding on a personalized approach to the prevention of respiratory syncytial virus in their infants.

Updates in the Management of HIV During Pregnancy.

Human immunodeficiency virus in pregnant people remains a significant public health issue worldwide. The rate of perinatal transmission is 15% to 40% but can be decreased to less than 1% with appropriate antenatal management. Previous recommendations included a protease inhibitor-based antiretroviral therapy, infant prophylaxis, performance of cesarean section for uncontrolled viremia, and the use of formula for infant feeding. However, recent updates include first line of integrase inhibitor-based regimens and supporting parental choices for safe lactation. In this review, we summarize and provide updated recommendations for the care of people living with human immunodeficiency virus during pregnancy.

Youth sociopolitical development: A conceptual framework by racial and gender minoritized youth organizers.

Youth sociopolitical development (SPD) is a powerful protective and promotive factor for marginalized adolescents' social, emotional, physical, and academic well-being. Despite having unique insight and experiential knowledge about SPD processes, youth have been excluded from conceptual framework and model development. As part of a Youth Participatory Action Research project, 11 adolescents (ages 14-19) and one adult ask "How do adolescent community organizers with varying social and political experiences conceptualize youth SPD?" We used a multiple case study design, with a grounded theory analytic approach. The YPAR collective identified four interrelated, experiential domains of youth SPD: thinking, feeling, doing and relating. Within each domain, we identified and defined key constructs and practices. The YPAR collective's qualitative inquiry resulted in more nuance for existing frameworks of critical consciousness and critical action, and the collective pushes the SPD field to better integrate social and emotional aspects of SPD practice. They offer a conceptual framework that is rooted in their experiential, sensory, learned, and social knowledge, from a multiple-marginalized positionality. These insights enrich the fields of SPD research and practice.

Placental Injury and Antibody Transfer after Coronavirus Disease 2019 in Pregnancy.

BACKGROUND: We examined the relationship between placental histopathology and transplacental antibody transfer in pregnant patients after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: Differences in plasma concentrations of anti-receptor biding domain (RBD) immunoglobulin (Ig)G antibodies in maternal and cord blood were analyzed according to presence of placental injury. RESULTS: Median anti-RBD IgG concentrations in cord blood with placental injury (n = 7) did not differ significantly from those without injury (n = 16) (median 2.7 [interquartile range {IQR}, 1.8-3.6] vs 2.7 [IQR, 2.4-2.9], P = 0.59). However, they were associated with lower transfer ratios (median 0.77 [IQR, 0.61-0.97] vs 0.97 [IQR, 0.80-1.01], P = 0.05). CONCLUSIONS: SARS-CoV-2 placental injury may mediate reduced maternal-fetal antibody transfer.

Impact of the COVID-19 Pandemic on Prenatal Care Utilization at a Public Hospital.

OBJECTIVE: The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts. RESULTS: We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p <0.001), and receive dating and anatomy ultrasounds (17.8 vs. 13.0%, p = 0.006 and 56.9 vs. 47.3%, p <0.001, respectively) compared with patients in the prepandemic cohort. There was no difference in mean number of prenatal care visits between the two groups (6.9 vs. 7.1, p = 0.18). Approximately 41% of patients in the pandemic-exposed cohort had one or more telehealth visits. The proportion of patients with one or more emergency department visits was higher in the pandemic-exposed cohort than the prepandemic cohort (32.8 vs. 12.3%, p < 0.001). Increases in rates of labor induction were also observed among the pandemic-exposed cohort (47.1 vs. 38.2%, p <0.001). CONCLUSION: Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic. KEY POINTS: · Patients initiated prenatal care earlier during the COVID-19 pandemic.. · Uptake of telehealth services was low.. · Rates of diabetes screening and ultrasound use increased during the pandemic..

The Effect of Antiretroviral Therapy for the Treatment of Human Immunodeficiency Virus (HIV)-1 in Pregnancy on Gestational Weight Gain.

BACKGROUND: Gestational weight gain above Institute of Medicine recommendations is associated with increased risk of pregnancy complications. The goal was to analyze the association between newer HIV antiretroviral regimens (ART) on gestational weight gain. METHODS: A retrospective cohort study of pregnant women with HIV-1 on ART. The primary outcome was incidence of excess gestational weight gain. Treatment effects were estimated by ART regimen type using log-linear models for relative risk (RR), adjusting for prepregnancy BMI and presence of detectable viral load at baseline. RESULTS: Three hundred three pregnant women were included in the analysis. Baseline characteristics, including prepregnancy BMI, viral load at prenatal care entry, and gestational age at delivery were similar by ART, including 53% of the entire cohort had initiated ART before pregnancy (P = nonsignificant). Excess gestational weight gain occurred in 29% of the cohort. Compared with non-integrase strand transfer inhibitor (-INSTI) or tenofovir alafenamide fumarate (TAF)-exposed persons, receipt of INSTI+TAF showed a 1.7-fold increased RR of excess gestational weight gain (95% CI: 1.18-2.68; P < .01), while women who received tenofovir disoproxil fumarate had a 0.64-fold decreased RR (95% CI: .41-.99; P = .047) of excess gestational weight gain. INSTI alone was not significantly associated with excess weight gain in this population. The effect of TAF without INSTI could not be inferred from our data. There was no difference in neonatal, obstetric, or maternal outcomes between the groups. CONCLUSIONS: Pregnant women receiving ART with a combined regimen of INSTI and TAF have increased risk of excess gestational weight gain.

Obstetric Outpatient Management During the COVID-19 Pandemic: Prevention, Treatment of Mild Disease, and Vaccination.

The majority of patients with coronavirus disease 2019 will have mild or asymptomatic disease, however, obstetric patients are uniquely at risk for disease progression and adverse outcomes. Preventive strategies including masking, physical distancing, vaccination, and chemoprophylaxis have been well studied, are critical to disease mitigation, and can be used in the pregnant population. High-quality data are needed to assess safety and effectiveness of therapeutics and vaccination in pregnancy, as well as long-term data on maternal and newborn outcomes.

Validation of Hypertensive Disorders During Pregnancy: ICD-10 Codes in a High-burden Southeastern United States Hospital.

BACKGROUND: Identification of hypertensive disorders in pregnancy research often uses hospital International Classification of Diseases v. 10 (ICD-10) codes meant for billing purposes, which may introduce misclassification error relative to medical records. We estimated the validity of ICD-10 codes for hypertensive disorders during pregnancy overall and by subdiagnosis, compared with medical record diagnosis, in a Southeastern United States high disease burden hospital. METHODS: We linked medical record data with hospital discharge records for deliveries between 1 July 2016, and 30 June 2018, in an Atlanta, Georgia, public hospital. For any hypertensive disorder (with and without unspecified codes) and each subdiagnosis (hemolysis, elevated liver enzymes, and low platelet count [HELLP] syndrome, eclampsia, preeclampsia with and without severe features, chronic hypertension, superimposed preeclampsia, and gestational hypertension), we calculated positive predictive value (PPV), negative predictive value (NPV) sensitivity, and specificity for ICD-10 codes compared with medical record diagnoses (gold standard). RESULTS: Thirty-seven percent of 3,654 eligible pregnancies had a clinical diagnosis of any hypertensive disorder during pregnancy. Overall, ICD-10 codes identified medical record diagnoses well (PPV, NPV, specificity >90%; sensitivity >80%). PPV, NPV, and specificity were high for all subindicators (>80%). Sensitivity estimates were high for superimposed preeclampsia, chronic hypertension, and gestational hypertension (>80%); moderate for eclampsia (66.7%; 95% confidence interval [CI] = 22.3%, 95.7%), HELLP (75.0%; 95% CI = 50.9%, 91.3%), and preeclampsia with severe features (58.3%; 95% CI = 52.6%, 63.8%); and low for preeclampsia without severe features (3.2%; 95% CI, 1.4%, 6.2%). CONCLUSIONS: We provide bias parameters for future US-based studies of hypertensive outcomes during pregnancy in high-burden populations using hospital ICD-10 codes.

Validation of ICD-10 Codes for Gestational and Pregestational Diabetes During Pregnancy in a Large, Public Hospital.

BACKGROUND: The use of billing codes (ICD-10) to identify and track cases of gestational and pregestational diabetes during pregnancy is common in clinical quality improvement, research, and surveillance. However, specific diagnoses may be misclassified using ICD-10 codes, potentially biasing estimates. The goal of this study is to provide estimates of validation parameters (sensitivity, specificity, positive predictive value, and negative predictive value) for pregestational and gestational diabetes diagnosis using ICD-10 diagnosis codes compared with medical record abstraction at a large public hospital in Atlanta, Georgia. METHODS: This study includes 3,654 deliveries to Emory physicians at Grady Memorial Hospital in Atlanta, Georgia, between 2016 and 2018. We linked information abstracted from the medical record to ICD-10 diagnosis codes for gestational and pregestational diabetes during the delivery hospitalization. Using the medical record as the gold standard, we calculated sensitivity, specificity, positive predictive value, and negative predictive value for each. RESULTS: For both pregestational and gestational diabetes, ICD-10 codes had a high-negative predictive value (>99%, Table 3) and specificity (>99%). For pregestational diabetes, the sensitivity was 85.9% (95% CI = 78.8, 93.0) and positive predictive value 90.8% (95% CI = 85, 97). For gestational diabetes, the sensitivity was 95% (95% CI = 92, 98) and positive predictive value 86% (95% CI = 81, 90). CONCLUSIONS: In a large public hospital, ICD-10 codes accurately identified cases of pregestational and gestational diabetes with low numbers of false positives.

Sociodemographic Predictors of SARS-CoV-2 Infection in Obstetric Patients, Georgia, USA.

We conducted a cohort study to determine sociodemographic risk factors for severe acute respiratory syndrome coronavirus 2 infection among obstetric patients in 2 urban hospitals in Atlanta, Georgia, USA. Prevalence of infection was highest among women who were Hispanic, were uninsured, or lived in high-density neighborhoods.

Hypertensive Disorders of Pregnancy, Cesarean Delivery, and Severe Maternal Morbidity in an Urban Safety-Net Population.

Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM), yet mediation by cesarean delivery is largely unexplored. We investigated the association between HDP and SMM in a cohort of deliveries at a safety-net institution in Atlanta, Georgia, during 2016-2018. Using multivariable generalized linear models, we estimated adjusted risk differences, adjusted risk ratios, and 95% confidence intervals for the association between HDP and SMM. We examined interactions with cesarean delivery and used mediation analysis with 4-way decomposition to estimate excess relative risks. Among 3,723 deliveries, the SMM rate for women with and without HDP was 124.4 per 1,000 and 52.0 per 1,000, respectively. The adjusted risk ratio for the total effect of HDP on SMM was 2.55 (95% confidence interval (CI): 2.15, 3.39). Approximately 55.2% (95% CI: 25.7, 68.5) of excess relative risk was due to neither interaction nor mediation, 24.9% (95% CI: 15.4, 50.0) was due to interaction between HDP and cesarean delivery, 9.6% (95% CI: 3.4, 15.2) was due to mediation, and 10.3% (95% CI: 5.4, 20.3) was due to mediation and interaction. HDP are a potentially modifiable risk factor for SMM; implementing evidence-based interventions for the prevention and treatment of HDP is critical for reducing SMM risk.

Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries.

BACKGROUND: Universal health coverage has been proposed as a strategy to improve health in low-income and middle-income countries (LMICs). However, this is contingent on the provision of good-quality health care. We estimate the excess mortality for conditions targeted in the Sustainable Development Goals (SDG) that are amenable to health care and the portion of this excess mortality due to poor-quality care in 137 LMICs, in which excess mortality refers to deaths that could have been averted in settings with strong health systems. METHODS: Using data from the 2016 Global Burden of Disease study, we calculated mortality amenable to personal health care for 61 SDG conditions by comparing case fatality between each LMIC with corresponding numbers from 23 high-income reference countries with strong health systems. We used data on health-care utilisation from population surveys to separately estimate the portion of amenable mortality attributable to non-utilisation of health care versus that attributable to receipt of poor-quality care. FINDINGS: 15·6 million excess deaths from 61 conditions occurred in LMICs in 2016. After excluding deaths that could be prevented through public health measures, 8·6 million excess deaths were amenable to health care of which 5·0 million were estimated to be due to receipt of poor-quality care and 3·6 million were due to non-utilisation of health care. Poor quality of health care was a major driver of excess mortality across conditions, from cardiovascular disease and injuries to neonatal and communicable disorders. INTERPRETATION: Universal health coverage for SDG conditions could avert 8·6 million deaths per year but only if expansion of service coverage is accompanied by investments into high-quality health systems. FUNDING: Bill & Melinda Gates Foundation.

The effect of adolescence and advanced maternal age on the incidence of complete and partial molar pregnancy.

OBJECTIVE: To compare the age-specific incidence of complete (CM) and partial molar (PM) pregnancy in a large tertiary care center in the United States. METHODS: Incidence rates of CM and PM per 10,000 live births were calculated using databases from Brigham and Women's Hospital, between 2000 and 2013. Age-specific rates were calculated for women younger than 20 years old (adolescents), 20-39 years old (average age), and 40 years and older (advanced maternal age). Pearson χ(2) test was used to evaluate potential differences among groups. Rate ratios (RR) and 95% confidence intervals (CI) were used to compare risk of molar pregnancy among average age women with that of adolescents and women of advanced age. Holm-Bonferonni adjustment was used to correct for multiple comparisons. RESULTS: Between 2000 and 2013, there were 255 molar pregnancies (140 CM and 115 PM) and 105,942 live births, corresponding to a molar pregnancy rate of 24 per 10,000 live births (95% CI 21-27). Rates of CM and PM were 13 (95% CI 11-16) and 11 (95% CI 9-14) per 10,000 live births respectively. The incidence of CM differed significantly among maternal age groups (p<0.001). Compared to average age women, adolescents were 7.0 times as likely to develop CM (95% CI 3.6-8.9, p<0.001), and women with advanced maternal age were nearly twice as likely (1.9, 95% CI 1.8-4.7, p=0.002). The rate of PM did not vary significantly among age groups (p=0.26). CONCLUSIONS: Adolescence and advanced maternal age were associated with increased risk of complete mole, but not partial mole.

Effect of race/ethnicity on risk of complete and partial molar pregnancy after adjustment for age.

OBJECTIVE: To quantify the effect of race/ethnicity on risk of complete and partial molar pregnancy. METHODS: We conducted a cross-sectional study including women who were followed for complete or partial mole and those who had a live singleton birth in a teaching hospital in the northeastern United States between 2000 and 2013. We calculated race/ethnicity-specific risk of complete and partial mole per 10,000 live births, and used logistic regression to estimate crude and age-adjusted relative risks (RR) of complete and partial mole. RESULTS: We identified 140 cases of complete mole, 115 cases of partial mole, and 105,942 live births. The risk of complete mole was 13 cases per 10,000 live births (95% confidence interval [CI] 11-16) and that of partial mole was 11 cases per 10,000 live births (95% CI 9-13). After age-adjustment, Asians were more likely to develop complete mole (RR 2.3 95% CI 1.4-3.8, p<0.001) but less likely to develop partial mole (RR 0.2; 95% CI 0.04-0.7, p=0.02) than whites. Blacks were significantly less likely than whites to develop partial mole (RR 0.4; 95% CI 0.2-0.8, p=0.01) but only marginally less likely to develop complete mole (RR 0.6; 95% CI 0.3-1.0, p=0.07). Hispanics were less likely than whites to develop complete mole (RR 0.4; 95% CI 0.2-0.7, p=0.002) and partial mole (RR 0.4; 95% CI 0.2-0.9, p=0.02). CONCLUSION: Race/ethnicity is a significant risk factor for both complete and partial molar pregnancy in the northeastern United States.

Effect of race/ethnicity on clinical presentation and risk of gestational trophoblastic neoplasia in patients with complete and partial molar pregnancy at a tertiary care referral center.

BACKGROUND: The reported incidence of molar pregnancy varies widely among different geographic locations. This variation has been attributed, at least in part, to racial/ethnic differences. While the incidence of molar pregnancies is decreasing, certain ethnic groups such as Hispanics, Asians, and American Indians continue to have an increased risk of developing gestational trophoblastic disease across the globe. OBJECTIVE: We sought to describe the potential effect of ethnicity/race on the presentation and clinical course of complete mole and partial mole. STUDY DESIGN: All patients followed up for complete mole and partial mole at a single institution referral center from 1994 through 2013 were identified. Variables including age, race, gravidity, parity, gestational age, presenting signs/symptoms, serum human chorionic gonadotropin values, and development of gestational trophoblastic neoplasia were extracted from medical records and patient surveys. Patients with complete mole and partial mole were categorized into race/ethnicity groups defined as white, black, Asian, or Hispanic. Due to low numbers of non-white patients with partial mole in each non-white category, patients with partial mole were grouped as white or non-white. Continuous variables were compared using the Kruskal-Wallis test and binary variables were compared using the Fisher exact test. RESULTS: A total of 167 complete mole patients with known race/ethnicity status were included (57.48% white, 14.97% Asian, 14.37% black, 13.17% Hispanic). Hispanics presented at younger age (median 24.5 years) compared to whites (median 32.0 years, P = .04) and Asians (median 31.0 years, P = .03). Blacks had higher gravidity than whites (P < .001) and Hispanics (P = .05). There was no significant difference in presenting symptoms, gestational age at diagnosis, and preevacuation serum human chorionic gonadotropin level by race/ethnicity. Hispanics were significantly less likely than whites to develop gestational trophoblastic neoplasia (absolute risk difference, 28.6%; 95% confidence interval, 8.1-39.2%; P = .02). A total of 144 patients with partial mole were analyzed. There were 108 white and 36 non-white patients. Median age was 31 years for white and 29 years for non-white patients (P = .006). Median gravidity was 2 for white and 3 for non-white patients (P < .001), and median parity was 0 for white patients and 1 for non-white patients (P = .003). There were no significant differences with respect to presenting signs and symptoms, gestational age, preevacuation human chorionic gonadotropin level, or risk of progression to gestational trophoblastic neoplasia. CONCLUSION: Hispanic patients with complete molar pregnancy had a significantly lower risk of developing gestational trophoblastic neoplasia than white patients. There were no significant differences among groups in terms of presenting symptoms, gestational age at diagnosis, or preevacuation human chorionic gonadotropin levels for either complete mole or partial mole patients.

Clinical Presentation of Complete Hydatidiform Mole and Partial Hydatidiform Mole at a Regional Trophoblastic Disease Center in the United States Over the Past 2 Decades.

OBJECTIVE: The aim of this study was to compare the clinical presentation and incidence of postmolar gestational trophoblastic neoplasia (GTN) among cases of complete mole (CM) and partial mole (PM) from 1994 to 2013. METHODS: This study included all cases of patients with CM and PM from our trophoblastic disease center between 1994 and 2013. Their clinical and pathologic reports were reviewed. Gestational age at evacuation, features of clinical presentation, human chorionic gonadotropin levels, and the rate of progression to GTN were compared. RESULTS: The median gestational age at evacuation was 9 weeks for CM and 12 weeks for PM (P < 0.001). Patients with PM had lower pre-evacuation serum human chorionic gonadotropin levels (P < 0.001), and they were also less likely to present with vaginal bleeding (P < 0.001), biochemical hyperthyroidism (P < 0.001), anemia (P < 0.001), uterine size greater than dates (P < 0.001), and hyperemesis (P = 0.002). Consequently, patients with PM were less likely to have been clinically diagnosed as moles compared with CM prior to uterine evacuation (P < 0.001). The development of GTN occurred in 17.7% (33/186) and 4.1% (7/169) of patients with CM and PM, respectively (P < 0.001). CONCLUSIONS: This study indicates that, at our center over the past 20 years, both CM and PM were usually evacuated in the first trimester of pregnancy. Because CM more commonly presents with the signs and symptoms of molar disease than PM, CM is more commonly diagnosed prior to evacuation.

Delay in chemotherapy administration impacts survival in elderly patients with epithelial ovarian cancer.

OBJECTIVES: The objective of this study was to characterize chemotherapy treatment patterns in elderly patients with epithelial ovarian cancer (EOC) and their impact on overall survival (OS). METHODS: We identified patients age ≥65years with stage II-IV EOC who underwent cytoreduction from 2003 to 2011. Relevant clinical variables were extracted and correlated with OS. Statistical analyses were performed using logistic regression, Kaplan-Meier methods, and multivariable Cox proportional hazard models. RESULTS: One hundred and eighty-four patients were included in the analysis. The average age was 73years with American Society of Anesthesiology Physical Status Class 2 or 3. Approximately 78% underwent primary debulking surgery (PDS). OS for the entire cohort was 3.3years. One hundred and fifty-seven patients received adjuvant chemotherapy, of which 70% received initial platinum-based doublet therapy; 67.5% of patients were able to complete the intended six cycles of chemotherapy; of these, 34% experienced a dose reduction and 45% experienced one or more dose delays. Any dose delay was associated with a decrease in overall survival (p=0.02) and remained significant even after controlling for age, stage, and residual disease and number of chemotherapy cycles received (p=0.029). CONCLUSIONS: Elderly EOC patients frequently required chemotherapy dose reductions and delays in chemotherapy administration. Multivariate analysis confirmed that dose delays are an independent factor associated with decreased OS.

Women with a partial mole during their first pregnancy and diagnosed earlier in gestation are at increased risk of developing gestational trophoblastic neoplasia.

OBJECTIVE: The aim of this study is to identify factors associated with gestational trophoblastic neoplasia (GTN) after partial molar pregnancy. METHODS: We retrospectively evaluated clinical data from 111 patients with a partial molar pregnancy between 1995 and 2010. RESULTS: A total of 111 patients with a partial molar pregnancy were available for analysis. There was no significant difference between patients who did and did not develop GTN with respect to patient age, parity, history of prior molar pregnancy, presenting signs/symptoms, uterine size greater than gestational age, clinical diagnosis, preevacuation sonogram findings, or the preevacuation human chorionic gonadotropin value. Patients who developed GTN had fewer prior pregnancies (median, 2 vs 3; P = 0.02) and were more likely to have had a partial molar pregnancy as their first gestational event (37.1% vs 17.1%; P = 0.03). Among the 35 patients who developed GTN, the median time to diagnosis of GTN was 47 days (range, 25-119 days), and the median human chorionic gonadotropin value at the time of GTN diagnosis was 475 mIU/mL (range, 20-52,630 mIU/mL). All women (100%) who developed GTN had stage I disease, and all patients (100%) had low-risk GTN. All 35 women (100%) were able to achieve remission, and most (85.7%) of these patients received methotrexate as first-line chemotherapy. CONCLUSIONS: Women with a partial molar pregnancy as their first gestational event and diagnosed earlier in gestation are more likely to develop postmolar GTN.

Pregnancy-Associated Firearm Mortality in the U.S., 2008-2019.

INTRODUCTION: This study analyzed the contribution of firearms to pregnancy-associated mortality from homicide and suicide. METHODS: This was a retrospective cohort study using the Centers for Disease Control and Prevention's National Violent Death Reporting System from 2008 to 2019. Women aged 15-44 years who died by suicide (intentional self-harm) and homicide where a firearm was involved were included. Persons without known pregnancy status were excluded. Pregnancy-associated deaths were defined as those that occurred during pregnancy or within 1 year of pregnancy (early and late postpartum). Sociodemographic characteristics and social and circumstantial differences were compared between pregnancy-associated and nonpregnant-associated deaths. Data analysis was conducted in 2022-2023. RESULTS: A total of 1,803 homicide and 1,929 suicide deaths from firearms were included. Twenty-two percent (n=388) and 11% (n=212) of firearm homicides and suicides, respectively, were pregnancy associated. Victims of pregnancy associated homicide were predominantly Black (54.8%), were single (76%), and had high school diploma or equivalent degree (41.2%). Victims of pregnancy-associated suicide were predominantly White (80.5%). Among pregnancy-associated homicides and suicides, deaths occurred more frequently during pregnancy (63.4% and 40.3%). Pregnancy-associated homicides more frequently occurred in the victim's home than nonpregnancy-associated homicides (51.5% vs 46.7%, p=0.02) and was related to ongoing conflict or violence between a current or former partner (61.6% vs 51.9%, p<0.001). Pregnancy-associated suicides more frequently occurred in those who experienced intimate partner violence within a month of death than non-pregnancy-associated suicide (4.2% vs 1.3%, p=0.005). CONCLUSIONS: Although there are differences in demographic characteristics between victims, interpersonal violence is associated with both pregnancy-associated homicides and suicides where a firearm was involved.